PATIENT SAFETYGhandi et al. reviewed four medical practices in Boston, two with traditional pen-and-paper prescriptions and two with basic e-prescribing. The investigators were unable to identify a significant difference in the rates of preventable ADEs between these two models. They speculated that part of the lack of difference was related to the non-advanced nature of e-prescribing in the groups that they studied, and they concluded that advanced systems could have avoided seven of the 20 preventable events.

The IOM recommends that health care organizations implement proven medication-safety processes, including computerized physician order entry (CPOE), to decrease medication errors and to improve health care in America. Evidence supporting the improved safety of advanced e-prescribing is beginning to take shape. A study in 2004 showed a 50% drop in paired alerts sent to prescribers in a renal unit after three weeks of exposure to the alerts, suggesting that sending the warnings directly to the physician contributed to their learning safer prescribing patterns.

According to David Bates, MD, who chairs the USP CPOE project team, computerized systems have great potential to improve practitioner prescribing, although functionality and design decisions will have a significant effect on the ability of the system to prevent prescribing errors. In his experience, the use of CPOE has decreased the incidence of serious medication errors by 55%. Each preventable ADE costs approximately $6,000. Currently, 62% of hospitals plan to implement CPOE in their facilities, and at the beginning of 2005, 23% of primary care physicians expected to purchase an electronic health record within the next 12 months.

More than a dozen CPOE vendor products are on the market; eight are already being used in hospitals beyond the pilot stage. Six of the most popular products are marketed by the following firms: Cerner, CliniComp, Eclipsys, Autros, Epic, and McKesson. The Leapfrog Group has developed a set of standards for CPOE to try to unify and standardize these systems.

The basic data for these systems, as well as for four layers of decision support, have been described in a White Paper from the USP.

E-prescribing has the potential to be coupled with intelligent decision support. Ideally, this technology would incorporate sophisticated data streams and enhance prescribing by providing patient-specific, prioritized, comprehensive, evidence-based clinical knowledge of monitoring at the moment the prescription is written. It has been projected that advanced e-prescribing will prevent 76% of avoidable errors annually; this figure represents 2,068,000 ADEs (136,100 of which would be life-threatening) and 191,000 hospitalizations. The promise of this technological advancement has yet to be realized or well documented. canadian antibiotics

EMERGING SOLUTIONS

Four potential solutions to the patient medication-safety dilemma are described here:

1. The Academy of Managed Care Pharmacy has developed and published Guiding Principles for Effective Electronic Messaging. As these principles become more widely adopted, they should significantly increase the value of safety alerts to pharmacists. Such standardized messages will be clearer, more action-focused, and less redundant than current alerts. These same enhancements will also benefit physicians who prescribe electronically.

2. The USP, among its many vital services, has formed a Therapeutic Decision Making Expert Committee to identify those drug-drug interactions for which the risk of harm is the greatest. The USP is evaluating the level of evidence connecting specific drug alerts with an eventual impact on health outcome. At the end of this process, the USP plans to issue recommendations regarding the appropriateness of including or excluding specific drug-drug interactions in a drug review safety pro-gram.
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3. Senior Outpatient Safety (“SOS Rx”), a broad collaborative coalition, has been convened by the National Consumer’s League under an unrestricted grant from Express Scripts. Representing consumers, caregivers, government agencies, retailers, health plans, pharmacy benefit managers, manufacturers, and professional societies, this group is focusing on advocacy for e-pre-scribing, personal medication records, education of high-risk patients, and the development of a clearinghouse of information about best practices for high-risk situations.

4. The Medicare Modernization Act of 2003 has introduced a number of initiatives for improving patient safety:

  • Pharmacy transactions will have to include both concurrent and retrospective DURs with associated safety interventions.
  • The adoption of e-prescribing will be accelerated.
  • An intervention called Medication Therapy Management Services will be implemented to improve self-management of complex medication regimens and to aid in detecting ADRs.

CONCLUSION

The field of safe prescribing in ambulatory medicine is emerging as a focus of study, with much work yet to be done. As with many opportunities for improvement, the answers can best be found in systems development rather than in blaming individuals for human error.
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This review has shown that past tragedies can draw attention to problems and possible solutions. Sorting through these potential solutions and debugging new systems will require dedication and persistence. An array of business entities with new products and services, consumer advocacy, and professional organizations is actively promoting this important agenda.